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Ask the Doctor

By Dr. Jack Burks
Chief Medical Officer for MSAA

Dr. Jack Burks

Q: I was diagnosed in 1991 with MS, although I have had symptoms since 1986. I worked as a registered nurse on a busy medical-surgery floor until 2002. I have had periods of vision loss at times, but when I go to bed, I sometimes can't sleep because I hear a "whirring noise" in my ears – almost like the sound of a fan running near my ear. Have you heard of anyone having this symptom, and what do you think it may be?

A: Noises in the ears, called tinnitus, can occur in MS patients as well as in people without MS, especially those subjected to loud noises from the environment (including loud music). Usually, the noise has a ringing quality but other noises can occur. In MS patients, it may be accompanied by balance problems and/or decreased hearing. However, MS patients can also have other (non-MS related) problems that must be considered, such as Meniere's disease. I recommend that you see an audiologist or otolaryngologist (an ear, nose, and throat specialist), who specializes in tinnitus. New treatments are being researched but no "standard" treatment is available. Noise-masking devices, electromagnetic stimulation therapy, and implanted electrodes are potential treatments being evaluated. General information about tinnitus may be found on www.webmd.com. An expert on tinnitus in your area can review your treatment options in detail.

Q: In addition to startling, I have also experienced some other symptoms which my neurologist says are not typical of MS. They include: fainting, vomiting, nausea, shortness of breath after short energy bursts (i.e., while vacuuming), and typical symptoms of having a heart attack (tightness on left side of chest, sore jaw, tingling down left arm, etc.). I've been to many different specialists this past year trying to chase these symptoms down. The cardiologist and pulmonologist say that my heart and lungs are in very good shape. My family practitioner suggested that my MS may be affecting my T-1, T-2, and T-3 (areas of spinal vertebrae). Have you heard of such symptoms and do you agree with my doctor's suggestion?

A: First, I cannot specifically comment on your family doctor's suggestion about an MS lesion in the thoracic spinal cord that may cause your symptoms. He or she knows you best. In my experience, I cannot recall such a variety of symptoms from a specific thoracic spinal cord MS lesion. You could get a spinal cord MRI to further investigate the possibility of spinal cord damage. I agree with your neurologist that many of your symptoms are not typical of MS. Therefore, I am pleased that your heart and pulmonary (lung) systems checked out okay.

If you cannot find a specific cause and treatment for your symptoms, relaxation techniques may help you to better deal with your symptoms, as they must be very frustrating to you. Biofeedback, self hypnosis, guided imagery, yoga, tai chi, and other techniques have helped many of my patients, even when I have been puzzled by their symptoms.

Q: I was diagnosed in 1999 with relapsing-remitting MS (RRMS) at the age of 39. My initial attack was quite severe. I was given steroids for a brief period and started on Avonex immediately. I have been on Avonex ever since, and as yet, have had no other relapses. Over the past nine years, I have had three MRIs, and these have shown no changes. The only symptom I experience is numbness in my hands. If I continue to be free of relapses in two years, when I turn 50, my doctor says he will recommend that I stop taking the Avonex (provided an MRI at that time shows no changes). What is your opinion in regards to stopping medication after years of no disease activity?

A: I am pleased that you have had no relapses since your initial episode. There are three ways to look at your good fortune. First, if you only had one attack, you might not have MS. For example, an entity called ADEM (acute disseminated encephalomyelitis) is similar to MS but does not usually recur. Second, your MS may be benign and you may not need treatment. However, I am concerned about this possibility because your initial attack was "quite severe" and "benign" may not stay "benign," even after several years. Third, you have MS and Avonex is working well, in which case you should not stop the drug. Ask your doctor about these and other possibilities in deciding on your future treatments.

Q: I'm 44 years old and last year I was given a diagnosis of "probable MS." Additionally, I was diagnosed with systemic lupus and arthritis in 1991; fibromyalgia in 2000; and hypothyroidism as well as diabetes in 2005. From my research, these are all autoimmune disorders. I had a spinal tap and a brain MRI; both were negative. My neurologist said that I do not have MS given the results of these tests. I've read extensively about autoimmune disorders and I've got to say that I still feel as though I may have MS. I don't have insurance and I haven't been able to work since April 2006, so I have no income other than my parents' ability to help with monthly expenses and medical care.

Over the past year, I have continued to experience sharp stabbing pain to my face, tingling and numbness of my lips and tongue, blurry vision and pain in my left eye, headaches, tremors, problems with my bladder (urgency, incontinence, and hesitation), extreme fatigue, excessive sweating, general pain, and cognitive problems. These symptoms cycle at different times over months.

Is it possible to have systemic lupus and MS? If so, what would be the best route of treatment? Thank you for your time and for caring.

A: Lupus and MS symptoms can overlap and the two illnesses may occur together, but this is very unusual. Also, as your neurologist pointed out, it is unlikely to have MS with a normal spinal tap and MRI. The first step to treatment is making a definite diagnosis. An MS specialist working with a rheumatologist is a reasonable next step. You did not mention any treatments for your lupus or fibromyalgia. Lyrica ® (pregabalin), a drug recently approved by the FDA for fibromyalgia, is something to discuss with your doctor. As for a potential MS connection, specific testing that evaluates your vision, bladder symptoms, and cognitive problems may help put your symptoms into better perspective. Your neurologist may want to repeat your brain MRI at some time in the future, if he or she has any further suspicions of MS.

Q: I was diagnosed with MS in 2004. Two years ago my neurologist sent me in for an MRI, and then a second MRI four months later. Six new spots were found (I had been on Copaxone), so I switched to Novantrone. The Novantrone is working for the disease, as I am having no new symptoms, but my existing symptoms seem to be getting worse. Can you tell me why this might be happening, and is this normal? I asked my doctor but he couldn't give me a definitive answer.

A: I am pleased you are having no new MS symptoms. However, worsening of existing symptoms may indicate that your disease is progressing. A repeat MRI might be helpful. Novantrone is only given for two to three years because of potential toxicity. What then? The other FDA-approved treatment options for MS (aside from Copaxone, which you tried earlier) are interferons and Tysabri. Your neurologist can review these treatments with you, relative to your specific situation. Also, there may be an MS center in your area that is doing a clinical trial on new drugs for MS, if you are interested. However, the first step is to have your neurologist determine if you are progressing. He or she may evaluate your MS according to your history, your examination, and possibly with an MRI. The next step will be to explore other treatment options.

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Jack Burks, MD, is a neurologist, chief medical officer for MSAA, clinical professor of neurology at the University of Nevada in Reno, Nevada, and member of the Clinical Advisory Committee of the NMSS. He has edited two MS textbooks. Previously, Dr. Burks established the Rocky Mountain MS Center and has served on several Boards of Directors, including the American Society of Neurorehabilitation (past president), the Colorado Neurological Institute, the American Academy of Neurology, and the Consortium of MS Centers. In recent years, he has lectured in more than 30 countries.